TMA: No Government Price Controls for Out-of-Network Billing Disputes
By Joey Berlin


The government shouldn’t set the fees physicians are paid for out-of-network care. 

That’s the message the Texas Medical Association is sending to key members of the U.S. Senate as lawmakers consider a troubling federal bill. 

First introduced last week, S. 1895, also known as the Lower Health Care Costs Act of 2019, would take patients out of the middle of disputes between physicians and health plans over fair out-of-network payment. Texas lawmakers did the same thing for many state-regulated plans in the Lone Star State with the passage of Senate Bill 1264 during this year’s legislative session. 

But the introduced version of S. 1895, sponsored by Sen. Lamar Alexander (R-Tenn.), would use government price controls – namely, the local median contracted commercial amount – as a reference point to determine out-of-network physician fees. 

In a letter sent to Senator Alexander and bill cosponsor Sen. Patty Murray (D-Wash.), TMA President David C. Fleeger, MD, explains that price controls the government already establishes for Medicare and Medicaid are arbitrarily set, fall below the cost of providing care, and are unsustainable. Both senators are members of the Health, Education, Labor, and Pensions Committee, which is considering the legislation; Senator Alexander is the committee chair. 

TMA is urging all physician, resident, student, and TMA Alliance members in Texas contact Republican Texas Sens. John Cornyn and Ted Cruz to ask for help in putting the brakes on S. 1895

TMA’s letter urges Congress to adopt a fair dispute resolution system like the baseball-style arbitration used with success in New York. On the other hand, the 2016 California surprise-billing law – which S. 1895 mirrors with its use of price controls – has exacerbated many health care delivery problems, the letter notes. 

“Extending government price controls to out-of-network services – especially using an unfair and inadequate rate such as the local median contracted commercial amount in the introduced version of S. 1895 – further threatens the viability of our practices and our patients’ access to the care they need,” Dr. Fleeger said in the letter. 

While patients deserve protection from balance billing, it shouldn’t come “at the expense of allowing health plans to control the health care market unilaterally,” TMA wrote. “It is imperative that (1) very robust network adequacy standards be promulgated and enforced to facilitate in-network contracting, and (2) insurers be held accountable for the deficiencies in products they sell when enrollees are forced to go out of network.” 

TMA’s letter also told Senators Alexander and Murray that market rates should be determined by an independent database that collects commercial health-plan payment data and sorts it by geographic area.  

Texas physicians, including Rep. Michael Burgess, MD (R-Lewisville), recently weighed in on a separate surprise-billing proposal during a U.S. House Committee on Energy and Commerce Subcommittee hearing.

Last Updated On

June 25, 2019

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Joey Berlin

Associate Editor

(512) 370-1393

Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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